We are presenting a surgical patient who underwent serious and ongoing events of sepsis, shock, bleeding, and massive transfusion that was successfully managed by the Anesthesia/ICU team.
67 year old morbidly obese male with Gleason 4+4 prostate CA s/p uneventful 6 hour robotic radical prostatectomy and RPLND and floor admission. Originally planned for discharge POD #3, he became distended from ileus, tachypneic, and tachycardic. CT revealed left pleural effusion and pelvic fluid collection. IR drained 550cc fluid, temporarily relieving respiratory distress. However, he became tachypneic, tachycardiac, hypoxic, and hemodynamically unstable that evening, during which time he became severely bradycardic, then pulseless, and required compressions, epinephrine, and atropine. Remaining hypotensive, he was taken to OR for abdominal compartment syndrome and underwent laparotomy, drainage, and loop colostomy.
Abdominal fluid cultures yielded E. Coli and Streptococcus, ultimately requiring cefepime and meropenem. Platelets dropped to 31, and pRBCs and platelets were given, and patient was stable for extubation on the third postoperative day. The next day he suddenly became diaphoretic, pale and hypotensive with severe right abdominal and flank pain and collapsed. He was resuscitated with fluid, and the Hb was found to be 6 indicating acute bleeding. Vascular consult was called. They suspected ruptured aortic aneurysm. Massive transfusion was started in ICU and patient was rushed to OR. Aortic clamps were placed as an emergent measure. On examination, aorta was intact and bleeding, pelvic in origin (erosion of vessels), and was uncontrollable. Patient rushed to IR for visceral angiogram and embolization of bilateral internal iliac and inferior mesenteric arteries. Diffuse oozing continued overnight. Amicar, Factor 7, and pressors were given with blood products. Patient then underwent partial abdominal closure and partial sigmoidectomy, followed by primary closure 2 days later.
Patient remained intubated, requiring blood products and platelets, and septic despite appropriate antibiotic coverage. He developed renal failure requiring dialysis, and required tracheostomy. Repeat CT showed several pockets of fluid collections inaccessible to surgery. Patient was taken to IR for abdominal drainage, during which there was acute bleeding indicating injury of a major vessel, and patient became hypotensive. He was resuscitated with blood products and taken to the OR. He was found to have a right epigastric artery bleed requiring ligation, after which 5 drains were placed. The patient required massive transfusion during this episode.
Antibiotics were continued, patient began to show signs of improvement, and renal function resumed. Dialysis was discontinued, and he was weaned off the respirator. Patient was transferred to floor 5 weeks after initial surgery. Over 2.5 weeks, he was de-lined, decannulated, and tolerating PO intake. After acute rehabilitation, he transferred home. He recently returned for stoma takedown.
In conclusion, this patient suffered numerous potentially fatal complications including massive hemorrhage and septic shock, and he required multiple surgeries and transfusions (~80 units pRBCs and 150 units blood products). The perioperative management was provided by the anesthetic team with expertise in both ICU and high risk anesthesia.
